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BCPS Exam > Critical Care: Intracranial Hemorrhage > Flashcards

Critical Care: Intracranial Hemorrhage Flashcards

1
Q

Describe the relative positions of meninges and bone

A
  1. The bone and dura mater lie against each other. The dura mater is tough and thin.
  2. The dura mater and arachnoid mater lie against each other on one side of the arachnoid mater. The arachnoid mater is “wider” but is not dense, it’s like bird bone or spider webs. (“connective-tissue trabeculae”) The not dense part is called the subarachnoid space. CSF flows inside of it.
  3. The Pia mater is under the subarachnoid space. It clings very tightly to the brain.
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2
Q

What are the three goals of care of intracranial hemorrhage (ICH) treatment

A
  1. Minimize hemorrhage expansion
  2. Treat associated organ dysfunction
  3. Decrease mortality and improved quality of life
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3
Q

What are the four classifications of ICH

A
  1. Intraparenchymal hemorrhage (IPH)
  2. Subarachnoid hemorrhage (SAH)
  3. Subdural hematoma (SDH)
  4. Epidural hematoma (EDH)
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4
Q

Describe an intraparenchymal hemorrhage

A

Nontraumatic bleeding into the brain parenchyma. also called intracerebral hemorrhage (ICH)

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5
Q

Describe subarachnoid hemorrhage

A
  1. Bleeding into the space between the pia and arachnoid membranes
  2. Patients may present early on with the classic “worst headache of my life.”
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6
Q

describe subdural hematoma

A

Bleeding between the dura and arachnoid space

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7
Q

Describe epidural hematoma

A

Bleeding between the dura and the bone

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8
Q

List the most common cause of subdural hematoma

A

Traumatic injury

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9
Q

List the most common cause of epidural hematoma

A

Traumatic injury

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10
Q

List five causes of subarachnoid hemorrhage

A
  1. Rupture of a cerebral aneurysm
  2. Bleeding from arteriovenous malformations
  3. Tumors
  4. Amyloid angiopathy
  5. Vasculopathy
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11
Q

List a common scale used to assess the level of consciousness

A

Glasgow Coma Scale (GCS)

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12
Q

List a common scale for strokes

A

National Institutes of Health Stroke Scale

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13
Q

List two scales specifically for subarachnoid hemorrhage (SAH)

A
  1. Hunt and Hess scale

2. Fisher scale

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14
Q

List a scale specifically for intraparenchymal hemorrhage

A
  1. ICH score (intracerebral hemorrhage score)
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15
Q

List the three components of the Glasgow Coma Scale

A
  1. Eye opening
  2. Motor response
  3. Verbal response
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16
Q

List the four options in the Eye Opening of GCS

A
  1. Does not open eyes (1)
  2. Opens eyes in response to painful stimuli (2)
  3. Opens eyes in response to voice (3)
  4. Opens eyes spontaneously (4)
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17
Q

List the six options in the Motor Response of GCS

A
  1. Makes not movements (1)
  2. Extension to painful stimuli (2)
  3. Abnormal flexion to painful stimuli (3)
  4. Flexion or withdrawal to painful stimuli (4)
  5. Localizes painful stimuli (5)
  6. Obeys commands (6)
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18
Q

List five options in the verbal Response of the GCS

A
  1. Makes no sounds
  2. Incomprehensible sounds
  3. Utters appropriate words
  4. Confused, disoriented
  5. Oriented, converses normally
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19
Q

Describe the Hunt and Hess scale

A
  1. Qualitative scale that rates patients with SAH from 1 (no symptoms) to 5 (deeply comatose)
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20
Q

Describe the Fisher scale

A

Rates the amount of blood present in patients with SAH from 1 (no blood visualized) to 4 (diffuse SAH, ICH, or intraventricular hemorrhage present)

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21
Q

Describe the Intracerebral hemorrhage (ICH) score

A

Composite score:

  1. Hemorrhage size,
  2. Age,
  3. Site of hemorrhage
  4. GCS scores
  5. Total composite ranges from 0 (best) to 6 (worst)
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22
Q

List six risk factors for intracranial hemorrhage

A
  1. Hypertension
  2. Use of blood thinner
  3. Amyloid angiopathy
  4. Intracranial aneurysm
  5. Liver failured-induced coagulopathy
  6. Mycotic (“infected”) aneurysms
23
Q

What is the most common risk factor of intracranial hemorrhage?

A

Hypertension

24
Q

List three types of blood thinners that cause increase risk of intracranial hemorrhage

A
  1. Fibrinolytics (e.g. alteplase)
  2. Anticoagulants
  3. Antiplatelets
25
Q

What is an amyloid angiopathy?

A

A collection of amyloid proteins on walls of blood vessels in brain

26
Q

List three modifiable risk factors for intracranial aneurysm

A
  1. Tobacco use
  2. Hypertension
  3. cocaine use
27
Q

List six non-modifiable risk factors for aneurysm rupture

A
  1. History of SAH
  2. Family history of SAH
  3. Large aneurysm size
  4. female sex
  5. Connective tissue disease
  6. Older age
28
Q

Rupture may be _____ or result from ____ or hypertension

A

Rupture may be spontaneous or may result from exertion or hypertension

29
Q

List six components of ICH and SAH treatment

A
  1. Blood pressure control
  2. Antifibrinolytic therapy
  3. Coagulation factors
  4. Seizure prophylaxis
  5. Vasospasm treatment
  6. Surgical
30
Q

The establishment of a BP goal in SAH should weigh what risks and balances

A
  1. AHA guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage recommend balancing the:
  2. Risk of stroke, rebleeding because of HTN, and maintenance of cerebral perfusion pressure.
31
Q

What is a reasonable systolic blood pressure goal in SAH?

A

Less than 160 mmHg

32
Q

In bloo pressure control in SAH, the agent should be ______ such as ______.

A
  1. Intravenous, titratable

2. Nicardipine, clevidipine

33
Q

For whom is antifibrinolytic therapy indicated?

A

For patients who will have a delay in surgical intervention

34
Q

What is the duration of antifibrinolytic therapy when indicated?

A

Less than 72 hours, or until angiography

35
Q

What agents are used when antifibrinolytic therapy is indicated?

A
  1. Aminocaproic acid 4-5 g load followed by 1/g hour.(preferred)
  2. Tranexamic acid. Many different protocols.
36
Q

Monitoring for patients receiving antifibrinolytic therapy must include

A

Development of a clot (VTE)

37
Q

Describe the use of coagulation factors in ICH

A

Recombinant activated factor VII decreased the size of ICH but did not improve outcomes

38
Q

Describe the difference in AHA guidelines in seizure prophylaxis between intracerebral hemorrhage and SAH, and explain why

A
  1. AHA guidelines on ACH recommend against prophylactic anticonvulsants,
  2. This may be because of early studies that used primarily phenytoin.
  3. However, the incidence of seizures in ICH is the same or slightly higher, however seizures can occur at onset or late in therapy (unlike SAH) because of scarring.
39
Q

What is the incidence of seizures in aneurysmal SAH/ICH?

A

May reach 20%

40
Q

What do seizures occur in aneurysmal SAH?

A

Primarily at the time of rupture

41
Q

AHA guidelines for antiepileptics in aneurysmal SAH recommend what?

A

Current guidelines state that prophylaxis can be considered in the immediate post hemorrhage period.

42
Q

Evidence fo antiepileptics in aneurysmal SAH is primarily conducted with what drug?

A

Phenytoin

43
Q

Why does the AHA and Neurocritical Care Society recommend to avoid using AHA in seizure prophylaxis for ICH

A

Drug interactions, especially with nimodipine (and likely nicardipine, maybe with clevidipine.)

44
Q

What is a generally safe antiepileptic to use in ICH? What’s the downside?

A
  1. Levetiracetam

2. Lack of data supporting its use

45
Q

What is a vasospasm?

A

Acute narrowing of the cerebral arteries after aneurysmal SAH

46
Q

When does vasospasm occur? When does the risk resolve?

A

Common during the first 7-10 days. Risk resolves after 21 days.

47
Q

What happens when vasospasm is untreated?

A

Leads to delayed cerebral ischemia. This is a major cause of death and disability

48
Q

How should vasospasm be treated?

A

Oral nimodipine 60 mg every 4 hours for 21 days for every patient, unless not tolerated because of hypotension

49
Q

What is a dosing adjustment for patients who cannot tolerate oral nimodipine standard dose?

A

Oral nimodipine 30 mg every 2 hours.

50
Q

What is the benefit of oral nimodipine?

A

Does not decrease incidence of vasospasm but it has been shown to improve outcomes.

51
Q

What is Triple-H therapy?

A
  1. No longer recommended. Stands for Hypertension, Hypervolemia, Hemodilution. Was historically used to prevent vasospasm.
52
Q

What is the ideal volume status for a patient in the post-hemorrhagic period?

A

Euvolemia should be maintained in all patients. Large volumes of hypotonic fluids should be avoided. Do not use Triple-H therapy.

53
Q

List two surgical procedures used for aneurysmal SAH that should be performed as early as possible

A
  1. microsurgical clip obliteration by craniotomy

2. Endovascular coiling

BCPS Exam (34 decks)

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